Laserfiche WebLink
Qu <br />SAN JOAQUIN COUNTY <br />4r ENVIRONMENTAL HEALTH DEPARTMENT <br />600 East Main Street, Stockton, CA 95202-3029 <br />Telephone: (209) 468-3420 Fax. (209) 468-3433 Web: www.sigov.org/ehd <br />UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br />Facility Name: Inspection Date: <br />Facility Address: N Servic Request #: <br />Onsite Service Technician's Name: e ec ni /installer Exp. Date: I Manufacturer Training: <br />19, <br />SERVICE <br />Leak detector <br />❑ <br />0 mechanical Model: <br />TH14 FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT EHDS CURRENT HOURLY RATE. <br />0 electronic Serial #: <br />Received By: <br />-- <br />0 line test programmed <br />Leak detector <br />El <br />0 mechanical Model: <br />0 electronic Serial #: <br />0 line test programmed <br />Leak detector <br />El <br />0 mechanical Model: <br />0 electronic Serial #: <br />0 line test programmed <br />sensor <br />El <br />0 positive shutdown Model: <br />0 fail safe Serial #: <br />DNA <br />sensor <br />0 positive shutdown Model: 3W LS -36 <br />0 fail safe Serial #: <br />0 NA <br />sensor <br />0 <br />0 positive shutdown Model: <br />El fail safe Serial #: <br />DNA <br />E-1 <br />Drop tube with mechanical overfill at 95% <br />0 <br />Drop tube with mechanical overfill at 95% <br />El <br />Overfill prevention (see LG letter 150-1) <br />0 <br />-50- <br />SERVICE <br />Spill bucket 0 minimum 5 gallon <br />El 0 1 hour hydrostatic El Incon TS -STS <br />El Caldwell System 0 Other <br />Spill bucket 0 minimum 5 gallon <br />El 0 1 hour hydrostatic El Incon TS -STS <br />0 Caldwell System I-] Other <br />Spill bucket 0 minimum 5 gallon <br />0 0 1 hour hydrostatic 0 Incon TS -STS <br />0 Caldwell System 0 Other <br />Primary piping testing at: <br />❑ psi <br />minutes <br />Secondary containment testing for: <br />UDC(s) Piping <br />Sump(s) LIST(s) <br />El Testing for the above components are next due by: <br />Note: Please be aware that 2- containment components are required to be tested upon <br />installation, 6 months after, and every 36 months thereafter. <br />❑ Cold start of monitoring panel <br />El Corrosion protection <br />El Other: see below <br />IF01m, MEN <br />TH14 FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT EHDS CURRENT HOURLY RATE. <br />EHD Inspecto!'41 <br />iiQ jF�� <br />Received By: <br />-- <br />EHD 23-04 <br />Rev 11/17//08 <br />UST SERVICE REQUEST INSPECTION REPORT <br />